Ethical Challenges and Stress for Health Care Professionals in Life Support Withdrawal

Abstract

Withdrawing life-sustaining treatment (WLST) in terminally ill patients’ presents significant ethical and emotional challenges for health care professionals. This cross-sectional study surveyed 436 health care providers at a teaching hospital in central Taiwan to explore the conflicts and stressors they face during WLST. Key ethical conflicts included unclear definitions of terminal illness, differing family attitudes, and ambiguous responsibility for extubation. Major stressors involved performing extubation, disclosing medical conditions, providing grief support, and navigating institutional procedures. Unmarried, younger, less experienced staff, particularly those without children or working in pediatric or surgical ICUs, were more susceptible to ethical stress (P <.01). Nurses and respiratory therapists reported more conflict over extubation responsibility, while physicians struggled more with defining terminal illness (P <.05). The findings highlight the need for clear guidelines, structured family meetings, multidisciplinary coordination, targeted education, emotional support systems, and broader public engagement with advance medical directives to reduce the ethical burden on health care professionals involved in WLST.

INTRODUCTION

Advances in medical technology have prolonged the lives of numerous individuals on the verge of death. Death has also become a ritualized and routine process rather than an act of nature. Nevertheless, as Tolstoy stated, the meaning of life is not found in reason but in life itself. To maintain patient dignity and ensure a good death or peaceful end-of-life experience, countries worldwide have promoted palliative care for individuals at the end of their lives. Within palliative care, the withdrawal of life-sustaining treatment (WLST) is often necessary to discontinue futile treatment when a patient is unable to express their values, beliefs, or preferences.¹ Taiwan introduced palliative care in 1987, enacted the Hospice Palliative Care Act in 2000, and incorporated WLST into legal regulations in 2013, becoming the first country in the Asia-Pacific region to legislate the right to a good death.^2,3 WLST refers to the discontinuation of life-sustaining treatment when a patient has reached the terminal stage of an illness with no possibility of improvement and serves to relieve suffering while prioritizing the patient’s best interests and respecting their medical autonomy or the decisions of a designated proxy.^3,4 Life-sustaining treatment involves interventions intended to prolong life, such as cardiopulmonary resuscitation, mechanical ventilation, ventricular assistance devices, antibiotics, dialysis, artificial nutrition and hydration, chest compressions, and enteral or parenteral nutrition or hydration.^5-7 The process of WLST involves patient rights, family preferences, professional medical judgment, interdisciplinary collaboration, and humanitarian care, making WLST a highly complex and ethically sensitive decision. WLST most commonly occurs in intensive care units; among adults, WLST often involves the refusal of cardiopulmonary resuscitation, dialysis, or mechanical ventilation. By contrast, among neonates, WLST is primarily used with extremely preterm infants.^5,8

WLST is frequently associated with the ethical concerns of saving versus taking a life, euthanasia, sanctity of life versus quality of life, and futile medical care. Throughout the WLST process, health care professionals are influenced by personal perspectives, legal and ethical considerations, the patient’s best interests, and moral factors, which can lead to internal conflicts and moral distress.^4,6,9 When decision-making time is limited or the prognosis is uncertain, the WLST process is often fraught with stress and conflict.^8,10 From the perspective of the sanctity of life, concerns frequently arise regarding the appropriateness of WLST decisions. Health care professionals may fear being perceived as executioners responsible for hastening death, worrying that patients whose lives are prolonged may endure lifelong disability and suffering, leading to feelings of guilt and moral burden.^6,9,10 When caring for critically ill patients in noncancer, surgical, or pediatric settings who have lost the ability to express their wishes, determining whether the patient has reached the end-of-life stage while balancing the patient’s best interests, family perspectives, and legal regulations often increases the complexity and psychological burden of decision-making.^10,11 The process of withdrawing respiratory support is not only a technical procedure but also a psychological and ethical challenge for health care professionals. Family reactions, feelings of guilt, sociocultural influences, and pressure within the hospital may negatively affect job satisfaction and mental well-being, potentially contributing to burnout.^3,9,10

In Taiwan, although WLST has been incorporated into legal regulations to safeguard patients’ right to a good death, interdisciplinary collaboration plays a crucial role in the WLST process. Health care professionals are key members of these interdisciplinary teams. The current shortage of health care professionals increases the urgency of understanding the ethical challenges they encounter in the workplace. A review of the literature revealed that although studies have examined the ethical challenges surrounding WLST, few have specifically explored these challenges and stress from the perspective of health care professionals. Elucidating the conflicts and pressures health care professionals encounter during the WLST process could help alleviate their psychological and emotional burdens, lead to policy adjustments, and improve the quality of end-of-life care. Therefore, this study aimed to (1) examine the ethical challenges and stress experienced by health care professionals in WLST, (2) explore the factors influencing these challenges, and (3) investigate differences in ethical challenges across health care professions. The study results may provide insights into the ethical conflicts and challenges health care professionals encounter in WLST and how these challenges vary across professional roles. These insights may improve the clinical work environment, enhance the quality of end-of-life care, and provide references for policy and educational development.

LITERATURE REVIEW

Challenges faced by health care professionals in WLST

In Taiwan, WLST applies to terminally ill patients. According to the Hospice Palliative Care Act, a “terminally ill patient” is defined as an individual who has a serious injury or illness and has been diagnosed by a physician as incurable, with medical evidence indicating a fatal prognosis. The term “fatal prognosis” refers to objective, evidence-based medical findings predicting a patient’s end of life within 3 to 6 months. In 2013, Taiwan officially incorporated WLST into its legal framework, enabling terminally ill patients to discontinue treatment. The WLST law also applies to individuals in an irreversible coma, those in a persistent vegetative state, patients with severe dementia, or those experiencing unbearable pain due to other conditions. The literature indicates that WLST is closely linked to health care costs and quality of life, rendering it highly complex and challenging.^7,12 In addition to ethical challenges, procedural disputes, and conflicts, the decision-making process requires careful consideration of whether WLST aligns with the patient’s best interests, informed consent, decision-making capacity, and medical autonomy.^6,7 For patients who lack decision-making capacity, common disputes involve whether family members should serve as proxies or advocates, whether they prioritize their own interests over those of the patient, and how the definition of family should be determined.³ Hence, shared decision-making and effective communication are critical to the WLST process.^13,14 However, communication can be complicated by geographical differences, cultural beliefs, values, and experiences, all of which may contribute to conflicts during decision-making.¹⁵

Intensive care units are common settings for controversies surrounding WLST. Challenges in the WLST process comprise the inability to determine patient wishes, concerns regarding violating legal regulations, the absence of legislative standards, uncertainty regarding when to initiate discussions with patients or their families, the appropriate timing for ventilator withdrawal, and the difficulty in predicting the time of death after withdrawal.^6,15 Critical care nurses play a complex and challenging role in WLST decision-making. The literature indicates that health care professionals’ attitudes toward WLST and their level of ethical sensitivity influence decision-making, and their attitudes toward WLST are positively correlated with their knowledge of the subject.^16,17 A study conducted in Italy indicated that pediatric intensive care professionals consider the lack of legislative standards for WLST a severe ethical problem. Clinicians often face distressing moral challenges during the decision-making process, and policymakers and professional associations should establish clinical guidelines to determine when patients have reached the terminal stage, ensuring adherence to the highest ethical standards.^3,6 Furthermore, Asian countries such as Taiwan have traditionally emphasized family and community rather than the individual. If a patient has not made an advance directive, disagreements among family members after the patient loses decision-making capacity can result in great stress.³ The burden of caring for dying patients after WLST may also increase stress among health care providers. Therefore, effective leadership and clear decision-making processes are essential for health care teams, families, and patients.¹⁸

Care process for WLST

The WLST process should prioritize the patient’s best interests. In addition to establishing clear objectives and a comprehensive care plan, a cross-team collaboration model should be adopted to ensure that family members fully understand the patient’s medical condition. This model enables families to consider their preferences, religious beliefs, values, and cultural backgrounds, helping patients or their families make informed decisions through careful deliberation, thorough discussions, and reflection.^3,6 When discussing WLST, the feelings of both the patient and their family members must be carefully considered to prevent feelings of abandonment.³ The literature on care before and after WLST processes emphasizes the need for two specialists to diagnose the patient as terminally ill, followed by a family consultation meeting for palliative care. This meeting should involve actively listening to family members’ concerns and ensuring the legal validity of their signed consent for the nonadministration of life-sustaining treatment.¹⁵ Discussion topics comprise the clinical evidence supporting the use of life-sustaining treatment in the patient’s condition, the probability of life extension, and the influence of extending life on the patient’s quality of life. If life-sustaining medical treatment is not provided or is withdrawn, the patient may experience disease progression and symptoms, and caregivers may be required to assume greater responsibilities.

The complexity of the mechanical ventilation withdrawal process involves individualized patient care, the needs of family members, and the stress experienced by health care professionals. A patient- and family-centered approach to care is essential.¹⁹ Key aspects of mechanical ventilation withdrawal care comprise clinical physicians’ perspectives and practices, time of death and predictive factors, analgesia and sedation practices, and physiological and psychological effects.²⁰ During the mechanical ventilation withdrawal process, disagreements may arise between clinical physicians and family members regarding the direction of care. Additionally, physicians, nurses, and respiratory therapists may differ on how extubation should be conducted. Conducting medical team meetings ensures that all team members participate in planning, communicate effectively, and formulate plans to resolve differences.¹⁹ Globally, considerable variations exist in the understanding, experience, and clinical practices related to the termination of mechanical ventilation. Additionally, the time between ventilation withdrawal and death is often unpredictable; however, physicians can use pharmacological interventions to manage potential distressing symptoms in patients. Health care professionals should also help patients and their families prepare psychologically and provide immediate and long-term care and support.²⁰ Endotracheal tube removal can enhance comfort and dignity at the end of life but may result in the patient making gurgling or gasping sounds. Although the psychological effect of extubation on patients, families, and health care professionals remains difficult to predict, current European guidelines recommend conducting the procedure on the basis of a consensus between medical professionals and family members.^19,21 To prevent postextubation stridor and discomfort, pharmacological treatment is recommended before extubation until symptoms stabilize. After extubation, spiritual care and grief counseling should be provided following the religious beliefs of the patient and their family.

This literature review highlights the challenges in implementing WLST and underscores the critical role of health care professionals in the process.

METHODS

Study design

This study adopted a cross-sectional design. Data collection occurred over a period from January 2017 to December 2018 and targeted health care professionals, specifically physicians, nurses, and other medical personnel, at a regional hospital in central Taiwan. The participants were recruited using convenience sampling to examine the ethical challenges and factors influencing health care professionals in the WLST process.

Participants

The inclusion criteria for this study were (1) being individuals who were able to communicate verbally or in writing, (2) being licensed health care professionals, and (3) being those who had provided care for patients on the verge of death. The exclusion criterion was being a health care professional without a valid license. Sample size estimation was conducted using the statistical design analysis system, with an alpha value set at .05 and statistical power at .08, resulting in an estimated sample size of 200 participants.

Research instruments

This study developed a self-designed questionnaire on the basis of the literature review. To ensure the validity and reliability of the questionnaire, five experts-one palliative care physician, one family medicine physician, one experienced head nurse, and two school teachers were invited to evaluate the appropriateness and clarity of the questionnaire’s content. A content validity assessment was also conducted, followed by a pilot test. The questionnaire comprised three sections: 1. Demographic information: This section contained 10 items assessing age, education level, nationality, marital status, sex, religious beliefs, seniority at work, job title, affiliated department, and parenthood. 2. Ethical challenges related to WLST: This section contained 15 items measured on a 5-point Likert scale with endpoints of 1 (strongly disagree) and 5 (strongly agree), with higher scores indicating greater ethical challenges. This scale’s content validity index (CVI) was .87, and the Cronbach’s alpha coefficient was .83. 3. Stress related to WLST: This section consisted of 10 items rated on a 10-point scale, with higher scores reflecting greater stress levels. The CVI for this scale was .90, and the Cronbach’s alpha coefficient was .89. Expert validation and pilot testing revealed that the questionnaire had adequate validity and reliability.

Data collection and analysis

After the authors obtained approval from the study institution’s institutional review board, the participants were recruited to complete the questionnaire. The collected questionnaires were screened, and those with excessive missing data or abnormal responses were excluded. The data were coded and processed using the Chinese version of SPSS 22.0. The following statistical analyses were conducted: (1) Descriptive Statistics: categorical variables were described using frequency distributions and percentages. Interval and ordinal variables were analyzed using frequency distributions, percentages, and mean values to understand their characteristics. (2) Inferential Statistics: t tests, a one-way analysis of variance (ANOVA), and post hoc tests were conducted to analyze the associations between categorical variables and ethical challenges.

Ethical considerations

This study was approved by the study institution’s institutional review board, and all participants signed an informed consent form after being informed of the study’s purpose and their rights. To ensure patient privacy, all data were encoded, used solely for research purposes, and not disclosed. Participants could withdraw at any time without their decision affecting their work.

RESULTS

Basic attributes of participants

A total of 436 health care professionals participated in this study. Among these, 411 (94.3%) were nurses, 16 (3.7%) were physicians, and 9 (2.1%) were respiratory therapists. Most participants were aged 20-29 years (255 participants; 58.5%). Regarding education level, 306 participants (58.5%) held a university degree. Unmarried individuals comprised 69.3% of the sample (302 participants). A total of 239 participants (54.8%) reported having religious beliefs. Women comprised 94.0% (410 participants) of the sample. In terms of seniority at work, the majority had over 5 years of experience (50.5%). Regarding affiliated departments, 145 participants (33.3%) worked in intensive care units, 52 (11.9%) in respiratory care centers, and 239 (54.8%) in general ward units (Table 1).

TABLE 1.

Essential Character of Participants N = 436

Item	n	%
Age
20-29	255	58.5
30-39	113	25.9
40 above	68	15.6
Education
Junior college	130	29.8
Bachelor	306	70.2
Country
Origin	433	99.3
Foreign	3	.7
Marital status
Unmarried	302	69.3
Married	134	30.7
Childbirth
No	319	73.2
Yes	117	26.8
Religious beliefs
No	197	45.2
Yes	239	54.8
Gender
Male	26	6.0
Female	410	94.0
Work seniority
≦1 years	84	19.3
>1 years≦5 years	132	30.3
>5 years	220	50.5
Occupation
Nurse	411	94.3
Physician	16	3.7
Respiratory Therapist	9	2.1
Unit
MICU	60	13.8
SICU	70	16.1
PICU	15	3.4
RCC	52	11.9
Ward	239	54.8

Ethical challenges and stress experienced by health care professionals in WLST

The results indicate that health care professionals experience various conflicts when faced with WLST. These conflicts comprise moral challenges (mean [M] = 3.09, standard deviation [SD] = .86), legal concerns (M = 3.07, SD = .90), role responsibilities (M = 3.10, SD = .91), divergent attitudes among family members (M = 3.35, SD = .87), uncertainty in responsibility for extubation (M = 3.14, SD = .94), uncertainty in disease prognosis (M = 3.13, SD = .79), and unclear definition of terminal illness (M = 3.39, SD = .84; Table 2). The top three conflicts encountered by health care professionals in WLST were unclear definitions of terminal illness, divergent attitudes among family members, and uncertainty in responsibility for extubation. Additionally, the lack of clear guidelines for determining the most appropriate timing for WLST had a mean score of 3.07 ± .82. Opposition to withdrawal due to concerns about preserving the patient’s right to life had a mean score of 2.07 ± .74. Feelings of guilt during the withdrawal of life-sustaining respiratory equipment, which was perceived as taking a patient’s life, had a mean ± standard deviation of 2.16 ± .81. Religious conflicts related to WLST had a mean score of 2.56 ± .89. Using a multidisciplinary collaboration model to address family concerns and disputes had a mean score of 1.58 ± .88, and care before and after the withdrawal of life-supporting equipment had a mean score of 1.39 ± .87. Additionally, the overall stress experienced by health care professionals when faced with WLST had a mean score of 4.73 ± 2.65, indicating moderate stress. The top five stressors were withdrawal of life-support systems or extubation (M = 5.58; SD = 2.68), disclosure of the patient’s condition (M = 5.19; SD = 2.53), grief counseling and emotional support for family members (M = 5.00; SD = 2.66), execution of the withdrawal process through cross-team collaboration (M = 4.89; SD = 2.49), and policies and procedures (M = 4.77; SD = 2.44) (Table 3).

TABLE 2.

Ethical Challenges by Health Care Professionals in WLST

Item	Mean	SD	Ranking
Moral challenges	3.09	.86
Legal concerns	3.07	.90
Role responsibilities	3.10	.91	5
Divergent attitudes among family members	3.35	.87	2
Uncertainty in responsibility for extubation	3.14	.94	3
The struggle to protect the right to life	2.07	.74
The guilt of the extubation	2.16	.81
Worried improper decisions affect the right to survival	2.99	.88
Uncertainty in disease prognosis	3.13	.79	4
Religious conflict	2.56	.89
Unclear definition of terminal illness	3.39	.84	1
Guide to saying thank you, saying goodbye, saying apologizing, etc	1.99*	.80
Lack of clear guidelines for appropriate timing for WLST	3.07	.82
Multidisciplinary collaboration model	1.58*	.88
Care before and after the withdrawal of life-supporting equipment	1.39*	.87

Strongly agree—5 points; Very agree—4 points; Agree—3 points; Disagree—2 points; Strongly disagree—1 point; * Reverse question.

TABLE 3.

Stress Experienced by Health Care Professionals in WLST

Items	Mean	SD	Ranking
Policy or procedure	4.77	2.44	5
Terminal illness diagnosis	4.69	2.48
Family counseling meeting	4.75	2.39
Disclosure of the patient’s condition	5.19	2.53	2
Doctor’s orders	4.23	3.53
Record Writing	4.66	2.65
Execution of the withdrawal process through multidisciplinary collaboration model	4.89	2.49	4
Withdrawal of life-support systems or extubation	5.58	2.68	1
Symptom management (eg, oxygen, analgesics, etc)	4.45	2.58
Quiet space provided after WLST	4.36	2.68
Saying thanks; love; sorry; forgiveness and goodbye	4.55	2.58
Body care	4.34	2.74
Grief counseling and emotional support for family members	5.0	2.66	3
Overall average	4.73	2.65

Factors influencing ethical challenges in WLST

An independent t test was used to explore the correlation between ethical dilemmas in WLST and variables such as participants’ education level, marital status, childbirth, and religious beliefs. The results revealed a statistically significant correlation between education level and unclear definitions of terminal illness (P = .012). The results of a further analysis indicated that participants with a university degree experienced greater ethical challenges related to unclear definitions of terminal illness than those with a junior college degree did. Additionally, participants with a university degree emphasized cross-team communication (P = .019) more than those without did. Marital status was significantly correlated with conflicts regarding the right to life (P = .024) and feelings of guilt (P = .037). Specifically, unmarried participants were more likely to experience ethical struggles regarding the right to life and were more prone to feelings of guilt than married participants. Regarding childbirth, participants who had never given birth reported significantly greater conflicts regarding the right to life (P = .043) than those with children did. Religious beliefs did not significantly affect WLST-related ethical challenges (Table 3). A one-way ANOVA was conducted to analyze the correlation between WLST-related ethical challenges and variables such as age, seniority at work, job title, and affiliated department. Age was statistically significantly correlated with role responsibility conflicts (P = .042), with younger health care professionals experiencing greater role-related conflicts in WLST than older professionals. Seniority at work significantly influenced struggles regarding the right to life (P = .035) and multidisciplinary communication (P = .011). The results of an analysis of the correlation between job category and WLST-related ethical challenges were as follows: Extubation conflicts were significantly greater among nurses and respiratory therapists than physicians (P = .028). Conflicts resulting from unclear definitions of terminal illness were greater among physicians than nurses (P = .013). Additionally, physicians perceived their own competence as significantly superior to that of nurses and respiratory therapists (P = .001). Finally, physicians rated their multidisciplinary communication (P = .002) and care before and after WLST (P = .001) significantly higher than nurses rated their performance across these variables. Regarding affiliated departments, conflicts regarding the right to life were greatest in surgical intensive care units, followed by internal medicine intensive care units (P = .001). Conflicts regarding the definition of terminal illness were greatest in pediatric intensive care units, followed by general ward units (P = .013) (Tables 4 and 5).

TABLE 4.

Factors Influencing Ethical Challenges in WLST (N = 436)

Items	Education				P	Marital Status				P	Childbirth				P	Religious Beliefs				P
	Junior college (n = 130)		Bachelor (n = 306)			Married (n = 134)		Unmarried (n = 302)			Yes (n = 117)		No (n = 319)			Yes (n = 239)		No (n = 197)
	mean	SD	mean	SD		mean	SD	mean	SD		mean	SD	mean	SD		mean	SD	mean	SD
Moral challenges	3.02	.80	3.12	.88	.27	3.01	.87	3.13	.85	.17	3.01	.83	3.12	.87	.22	3.12	.86	3.06	.87	.49
Legal concerns	3.10	.79	3.06	.95	.69	2.96	.89	3.13	.91	.07	2.96	.85	3.12	.92	.10	3.08	.91	3.06	.91	.79
Role responsibilities	2.99	.82	3.15	.95	.08	3.02	.95	3.14	.89	.21	3.00	.93	3.14	.91	.15	3.12	.92	3.08	.91	.64
Attitudes among family members	3.32	.79	3.37	.90	.57	3.29	.81	3.38	.89	.32	3.29	.79	3.37	.90	.35	3.33	.84	3.38	.90	.59
Responsibility for extubation	3.11	.84	3.16	.98	.61	3.10	.96	3.16	.93	.50	3.04	.91	3.18	.95	.18	3.18	.93	3.09	.95	.30
The struggle of right to life	2.10	.70	2.06	.77	.57	1.96	.66	2.12	.78	.024*	1.96	.66	2.11	.78	.043*	2.03	.67	2.11	.83	.28
The guilt of the extubation	2.16	.82	2.16	.81	.98	2.04	.73	2.21	.84	.037*	2.07	.70	2.19	.85	.11	2.18	.81	2.13	.81	.50
Worried improper decisions affect the survival	2.98	.93	3.00	.87	.83	2.90	.90	3.03	.87	.13	2.91	.93	3.02	.86	.27	3.03	.93	2.95	.83	.37
Uncertainty in disease prognosis	3.12	.78	3.14	.81	.86	3.16	.78	3.12	.80	.68	3.20	.78	3.11	.80	.31	3.13	.82	3.13	.77	.98
Religious conflict	2.55	.86	2.57	.91	.83	2.47	.90	2.60	.89	.16	2.52	.85	2.57	.91	.58	2.58	.88	2.54	.91	.64
Unclear definition of terminal illness	3.25	.75	3.45	.88	.012*	3.39	.90	3.39	.82	.94	3.43	.90	3.38	.83	.60	3.36	.85	3.43	.84	.44
Good end of life guidance	2.90	.74	3.06	.83	.06	3.02	.81	3.00	.80	.82	3.08	.81	2.98	.80	.28	2.99	.81	3.04	.80	.53
Lack of clear guidance	3.08	.72	3.06	.87	.86	3.01	.82	3.09	.83	.32	2.95	.80	3.11	.84	.07	3.06	.80	3.07	.86	.91
Multidisciplinary communication	3.28	.78	3.48	.92	.019*	3.54	.91	3.37	.86	.06	3.57	.93	3.36	.86	.035*	3.38	.89	3.46	.87	.36
Pre- and postextubation care	3.49	.81	3.66	.90	.05	3.66	.92	3.59	.85	.48	3.68	.92	3.59	.86	.36	3.58	.87	3.65	.88	.35

^*P < .05, **P < 0.01, ***P < .001; independent t test.

TABLE 5.

Factors Influencing Ethical Challenges in WLST (N = 436)

Items	Age	N	Mean	SD	P	Work Seniority	N	Mean	SD	P	Occ.	N	Mean	SD	P	Unit	N	Mean	SD	P
Moral challenges	20-29	255	3.15	.87	.26	≦1 years	84	3.12	.92	.37	Nurse	411	3.11	.84	.16	MICU	60	3.17	.92	.47
	30-39	113	3.04	.86		>1≦5 years	132	3.17	.87		Doctor	16	2.69	1.30		SICU	70	2.93	.77
	≥40	68	2.97	.83		>5 years	220	3.04	.83		RT	9	3.11	.78		NICU	15	3.00	1.00
																RCW	52	3.10	.75
																Ward	239	3.13	.88
Legal concerns	20-29	255	3.10	.93	.57	≦1 years	84	3.10	.87	.67	Nurse	411	3.09	.90	.22	MICU	60	3.18	.91	.11
	30-39	113	3.07	.90		>1≦5 years	132	3.12	.96		Doctor	16	2.69	1.14		SICU	70	2.94	.74
	≥40	68	2.97	.85		>5 years	220	3.04	.89		RT	9	3.11	.78		NICU	15	2.60	1.06
																RCW	52	3.19	.77
																Ward	239	3.09	.96
Role responsibilities	20-29	255	3.18	.91	.042*	≦1 years	84	3.15	.91	.41	Nurse	411	3.12	.89	.10	MICU	60	3.07	.97	.78
	30-39	113	3.05	.92		>1≦5 years	132	3.17	.93		Doctor	16	2.63	1.31		SICU	70	3.00	.76
	≥40	68	2.88	.86		>5 years	220	3.05	.91		RT	9	3.11	.78		NICU	15	3.00	1.07
																RCW	52	3.12	.83
																Ward	239	3.15	.95
Attitudes among family members	20-29	255	3.42	.89	.17	≦1 years	84	3.45	.84	.10	Nurse	411	3.36	.86	.69	MICU	60	3.38	.96	.06
	30-39	113	3.27	.86		>1≦5 years	132	3.43	.93		Doctor	16	3.31	1.20		SICU	70	3.17	.85
	≥40	68	3.24	.79		>5 years	220	3.26	.84		RT	9	3.11	.33		NICU	15	3.07	1.03
																RCW	52	3.21	.72
																Ward	239	3.44	.86
Responsibility for extubation	20-29	255	3.17	.95	.32	≦1 years	84	3.15	.84	.85	Nurse	411	3.16	.92	.028*	MICU	60	3.05	.98	.068
	30-39	113	3.18	.95		>1≦5 years	132	3.17	.98		Doctor	16	2.56	1.21		SICU	70	3.07	.82
	≥40	68	2.99	.91		>5 years	220	3.12	.95		RT	9	3.44	.88		NICU	15	3.20	1.26
																RCW	52	3.29	.94
																Ward	239	3.15	.95
The struggle of right to life	20-29	255	2.11	.80	.28	≦1 years	84	2.23	.91	.035*	Nurse	411	2.07	.76	.76	MICU	60	2.18	.70	.001**
	30-39	113	1.97	.70		>1≦5 years	132	2.11	.71		Doctor	16	1.94	.68		SICU	70	2.39	.89
	≥40	68	2.09	.62		>5 years	220	1.99	.69		RT	9	2.11	.33		NICU	15	2.00	.85
																RCW	52	2.00	.56
																Ward	239	1.97	.72
The guilt of the extubation	20-29	255	2.20	.87	.55	≦1 years	84	2.21	.91	.11	Nurse	411	2.17	.81	.18	MICU	60	2.27	.94	.48
	30-39	113	2.11	.72		>1≦5 years	132	2.26	.87		Doctor	16	1.81	.91		SICU	70	2.20	.81
	≥40	68	2.12	.72		>5 years	220	2.08	.73		RT	9	2.33	.71		NICU	15	2.07	.88
																RCW	52	2.27	.69
																Ward	239	2.10	.80
Worried improper decisions affect the survival	20-29	255	3.03	.94	.50	≦1 years	84	3.01	.84	.21	Nurse	411	3.00	.89	.18	MICU	60	2.92	.87	.09
	30-39	113	2.95	.79		>1≦5 years	132	3.09	.98		Doctor	16	2.63	.81		SICU	70	2.81	.84
	≥40	68	2.91	.82		>5 years	220	2.92	.84		RT	9	3.22	.44		NICU	15	2.80	1.08
																RCW	52	3.23	.73
																Ward	239	3.02	.91
Uncertainty in disease prognosis	20-29	255	3.09	.84	.17	≦1 years	84	3.12	.78	.94	Nurse	411	3.12	.80	.61	MICU	60	3.08	.83	.12
	30-39	113	3.13	.75		>1≦5 years	132	3.12	.89		Doctor	16	3.31	.79		SICU	70	2.94	.76
	≥40	68	3.29	.67		>5 years	220	3.15	.74		RT	9	3.22	.67		NICU	15	2.93	.70
																RCW	52	3.21	.64
																Ward	239	3.20	.83
Religious conflict	20-29	255	2.62	.95	.22	≦1 years	84	2.62	.96	.22	Nurse	411	2.57	.89	.53	MICU	60	2.50	.89	.78
	30-39	113	2.45	.80		>1≦5 years	132	2.64	.92		Doctor	16	2.31	1.14		SICU	70	2.67	.85
	≥40	68	2.51	.82		>5 years	220	2.49	.85		RT	9	2.56	.53		NICU	15	2.47	.92
																RCW	52	2.60	.75
																Ward	239	2.54	.94
Unclear definition of terminal illness	20-29	255	3.35	.84	.11	≦1 years	84	3.40	.76	.54	Nurse	411	3.37	.85	.013*	MICU	60	3.20	.80	.013*
	30-39	113	3.37	.83		>1≦5 years	132	3.33	.90		Doctor	16	4.00	.82		SICU	70	3.17	.87
	≥40	68	3.59	.90		>5 years	220	3.43	.84		RT	9	3.44	.53		NICU	15	3.67	.90
																RCW	52	3.38	.69
																Ward	239	3.49	.86
Good end of life guidance	20-29	255	3.01	.78	.60	≦1 years	84	2.96	.72	.25	Nurse	411	2.98	.78	.001**	MICU	60	2.90	.75	.61
	30-39	113	2.96	.83		>1≦5 years	132	3.11	.85		Doctor	16	3.75	1.06		SICU	70	3.13	.76
	≥40	68	3.09	.86		>5 years	220	2.97	.81		RT	9	2.89	.93		NICU	15	3.00	.65
																RCW	52	3.00	.79
																Ward	239	3.00	.84
Lack of clear guidance	20-29	255	3.09	.85	.39	≦1 years	84	3.08	.76	.86	Nurse	411	3.06	.83	.37	MICU	60	2.97	.74	.67
	30-39	113	3.08	.83		>1≦5 years	132	3.09	.87		Doctor	16	3.00	.89		SICU	70	3.10	.80
	≥40	68	2.94	.77		>5 years	220	3.05	.83		RT	9	3.44	.73		NICU	15	3.13	.92
																RCW	52	3.19	.72
																Ward	239	3.05	.88
Multidisciplinary communication	20-29	255	3.34	.90	.06	≦1 years	84	3.24	.90	.011*	Nurse	411	3.39	.87	.002**	MICU	60	3.27	.90	.06
	30-39	113	3.50	.86		>1≦5 years	132	3.33	.86		Doctor	16	4.19	.91		SICU	70	3.30	.75
	≥40	68	3.59	.83		>5 years	220	3.54	.87		RT	9	3.33	.71		NICU	15	3.60	.91
																RCW	52	3.25	.62
																Ward	239	3.52	.95
Pre- and post-extubation care	20-29	255	3.53	.87	.07	≦1 years	84	3.56	.75	.09	Nurse	411	3.59	.86	.001**	MICU	60	3.53	.89	.09
	30-39	113	3.73	.89		>1≦5 years	132	3.50	.90		Doctor	16	4.38	.89		SICU	70	3.51	.88
	≥40	68	3.71	.83		>5 years	220	3.70	.90		RT	9	3.33	.71		NICU	15	3.60	.91
																RCW	52	3.38	.66
																Ward	239	3.71	.90

^*P < .05

^**P <.01

^***P < .001; one-way ANOVA. Occ., occupation; MICU, medical intensive care unit; SICU, surgical intensive care unit; NICU, neonatal intensive care unit; RCW, respiratory care ward.

DISCUSSION

Ethical challenges in WLST

Health care professionals often encounter conflicts during the WLST process, specifically unclear definitions of terminal illness, divergent attitudes among family members, uncertainty in responsibility for extubation, uncertainty in disease prognosis, role responsibilities, moral challenges, legal concerns, and the most appropriate timing. Unclear definitions of terminal illness, divergent attitudes among family members, and uncertainty in responsibility for extubation were the top three ethical challenges reported by health care professionals in the WLST process. Although Taiwan incorporated WLST into its legal framework in 2013, enabling terminally ill patients to withdraw life-sustaining treatment to die well and with dignity, the results of this study revealed that health care professionals encounter challenges when determining whether critically ill noncancer patients and neonates have reached the final stage of life. The primary cause of these challenges is the unclear definition of terminal illness in these patient groups and the lack of national standards and guidelines for WLST implementation. Across professional roles, physicians and pediatric intensive care unit professionals reported the highest level of internal conflicts, with statistically significant differences among professional roles. Physicians, who are responsible for diagnosing patients, often base WLST decisions on the principle of maximizing benefits. However, determining an infant’s best interest in neonatal care is challenging, involving factors such as relative survival risks, the concept of best interests, the sanctity of life, parental autonomy and decision-making, and the equitable allocation of medical resources.

Health care professionals and parents may perceive the concept of best interest differently. Additionally, the decision-making rights and responsibilities of parents, health care professionals, and neonates are often unclear. Therefore, when a patient’s survival or quality of life is uncertain, physicians often experience ethical challenges, internal conflicts, and moral distress and endure the burden of responsibility, inner struggles, and suffering.^6,9,10 Ethical decision-making in neonatal end-of-life care has shifted from the traditional physician as an information provider model to a shared decision-making process between physicians and families. For patients lacking decision-making capacity, common controversies in decision-making involve whether family members are suitable proxies or advocates, whether they prioritize their interests over the patient’s, and the definition of family.³ Shared decision-making and communication are critical steps in the WLST process.¹³ However, conflicts may arise due to differences in geographic location, culture, beliefs, personal preferences, and experiences.¹⁵ Furthermore, in some countries, neonatal medical societies reaffirm the right to life in end-of-life care, requiring consensus between the medical team and the family before initiating do-not-resuscitate orders or WLST.¹⁰ This study highlights the urgent need for clear WLST guidelines and standardized definitions of terminal illness for neonates and critically ill noncancer patients. Specialized medical societies must conduct in-depth discussions and establish field-specific guidelines to reduce challenges in clinical practice.

When making WLST decisions, divergent attitudes among family members and physicians are a major ethical challenge experienced by health care professionals. The findings of this study indicate that nurses, physicians, and respiratory therapists all experience stress when divergent attitudes arise. These divergent attitudes may stem from differences in consensus among family members or disputes between families and medical professionals regarding disclosing the patient’s condition. During the WLST process, shared decision-making and communication are crucial steps that enable family members to express their preferences and have a voice in the decision.^10,13 To ensure that patient well-being remains the priority, health care teams must establish clear goals and care plans and utilize a multidisciplinary collaboration model. This approach helps family members comprehensively understand the patient’s medical condition and recognize their preferences, beliefs, values, and culture, facilitating thoughtful, well-discussed, and reflective decision-making for the patient or their family.^3,6 When discussing WLST, the feelings of both patients and their families must be considered to prevent feelings of abandonment.³ Holding palliative care family consultation meetings, patiently listening to family concerns, and ensuring the legal validity of the consent form for extubation are crucial.¹⁵ Additionally, after WLST is implemented and the patient dies, continued support and care should be provided to family members and health care staff.¹³

Furthermore, the results of this study indicate that nurses and respiratory therapists experience considerably greater internal conflict regarding uncertainty in responsibility for extubation than physicians do. This finding may be attributable to the lack of explicit regulations specifying who should perform extubation in clinical practice. Although most guidelines stipulate that physicians should conduct extubation, some suggest that it should be conducted by family members, respiratory therapists, or nurses. In Taiwan, where the medical system tends to follow a paternalistic model, respiratory therapists, and nurses often experience intense pressure when following extubation orders. Additionally, WLST involving the removal of life-supporting respiratory equipment is frequently associated with debates on euthanasia and assisted suicide. Health care professionals involved in the extubation process may experience guilt, feeling as though they are taking the patient’s life. If the timing of WLST is controversial or violates legal regulations, they may also fear potential criminal liability. Consistent with the findings of the literature, the findings of this study reveal that health care professionals often face pressure from families, societal and cultural expectations, and institutional policies during WLST. Due to the belief in the sanctity of life, health care professionals often experience guilt and moral distress, feeling as if they are facilitating death, which may intensify their emotional burden.^6,9

Health care professionals involved in WLST encounter not only ethical challenges, such as concerns regarding violating legal regulations, uncertainty about when to initiate conversations with patients or families, and when to withdraw ventilatory support,^6,15 but also experience internal conflicts, such as unclear definitions of terminal illness, divergent attitudes among family members, uncertainty in responsibility for extubation, uncertainty in disease prognosis, role responsibilities, and the most appropriate timing for WLST.

Exploration of stress in WLST

The results of this study indicate that health care professionals typically experience a moderate level of stress when facing WLST. The top five stressors are withdrawal of life-support systems or extubation, disclosure of the patient’s condition, grief counseling and emotional support for family members, execution of the withdrawal process through cross-team collaboration, and policies and procedures. The withdrawal of life-support systems (eg, extubation or discontinuation of mechanical ventilation) is a critical moment in medical practice and often leads to feelings of guilt among health care professionals, who may equate it with murder. The findings of this study demonstrate that the withdrawal of life-support systems or extubation is the most stressful task for health care professionals. The absence of clear standards and guidelines further exacerbates decision-making uncertainty and psychological burdens. The literature indicates that withdrawing mechanical ventilation involves patient factors, family needs, and the emotional burden on health care professionals. Hence, patient- and family-centered care is crucial.¹⁹ Additionally, the time between ventilator withdrawal and death is often unpredictable. Physicians may use pharmacological interventions to manage distressing symptoms experienced by patients. Health care professionals should help patients and their families prepare emotionally and provide immediate and long-term care and support.²⁰ To prevent stridor and discomfort after extubation, pre-extubation medication management is recommended until symptoms stabilize. Following extubation, spiritual care and grief counseling should be provided to patients and their families per their religious beliefs and cultural preferences.

In the WLST process, disclosing the patient’s condition is essential. Nevertheless, effectively communicating prognosis and establishing consensus with the family remains a major challenge for health care professionals. This difficulty is increased when family members have a limited understanding of the patient’s condition or unrealistic expectations. Health care professionals must balance honest disclosure with minimizing emotional distress. Implementing empathetic communication techniques and a phased approach to delivering information can help reduce anxiety for patients and families and ease communication-related stress for health care providers. For patients lacking decision-making capacity, advocating for family participation in decision-making and integrating communication skills training into medical and nursing education^4,17 are crucial. Families often experience intense grief and emotional distress following WLST. Thus, in addition to providing professional medical care, health care professionals must serve as emotional support providers, which can lead to emotional exhaustion or compassion fatigue. Without proper psychological support mechanisms, prolonged exposure to these situations may result in burnout.^19,20 Therefore, medical institutions should provide adequate psychological support, such as emotional debriefing sessions, clinical supervision, or peer support groups, to help health care professionals manage stress. The decision-making and execution of WLST require collaboration across multiple professional roles, such as physicians, nurses, social workers, psychologists, and chaplains. The quality of multidisciplinary collaboration directly affects decision-making and execution efficiency. However, in clinical practice, differences in perspectives among team members regarding withdrawal criteria, timing, or role responsibilities may hinder smooth decision-making. Additionally, caring for dying patients after WLST may increase the stress on health care staff. Clear communication, collaboration within teams, and effective leadership and decision-making can reduce staff stress.¹⁸ If the team lacks clear communication channels and a consensus-building mechanism, health care professionals may experience stress due to information asymmetry. Establishing a standardized cross-team decision-making process and a regular family meeting mechanism can reduce the decision-making burden and communication pressure on health care professionals. If hospitals lack clear ethical guidelines or standard operating procedures, health care professionals must weigh several factors independently when handling cases, leading to increased burdens. Regarding policies or procedures, medical institutions and national regulations may have inconsistent policies regarding WLST, resulting in legal and ethical pressure for health care professionals during execution. Well-developed policies and clinical guidelines can enhance confidence in decision-making and execution and reduce unnecessary stress.^19,21 To alleviate stress among health care professionals, medical institutions should establish standardized extubation guidelines, strengthen physician–patient communication training to enhance skills in disclosing medical conditions and providing emotional support, promote a multidisciplinary decision-making model to ensure team consensus and collaboration, and provide emotional support (psychological counseling, emotional relief programs, peer support systems).

Factors influencing ethical challenges in WLST

The results of this study indicate that the extent of ethical dilemmas in WLST is associated with factors such as education level, marital status, childbirth experience, age, seniority at work, job title, and affiliated department. According to the findings of this study, individuals with higher education levels, those who are unmarried, those without childbirth experience, those who are younger, and those with lower seniority at work are more likely to experience ethical challenges. Younger health care professionals are more prone to role responsibility conflicts than their older counterparts. Younger professionals may view their roles as saving lives and curing patients. When faced with WLST, they may feel as if they are abandoning the patient or actively contributing to the patient’s death, leading to conflicts in professional roles. By contrast, older professionals hold different views on medical treatment, the meaning of life, and what constitutes a good death, resulting in fewer role responsibility conflicts. Additionally, married individuals and those who have had children tend to be more accepting of WLST, likely due to a greater emphasis on overall family functionality and quality of survival. Furthermore, the results of the present study indicate that job titles and affiliated departments also influence responses to ethical challenges. Specifically, respiratory therapists and nurses reported greater conflicts regarding extubation than physicians did. By contrast, physicians exhibited greater confidence and awareness in areas such as providing guidance on good death, engaging in cross-team communication, and providing care before and after WLST, resulting in substantially reduced ethical challenges compared with nurses and respiratory therapists. This finding may be attributed to the state of medical education in Taiwan, where medical ethics is integrated into the curriculum. Physicians have ample opportunities to engage in case-based discussions and scenario-based ethical reflections that enable them to think through and reflect on ethical challenges. By contrast, ethics training and discussions are relatively limited in nursing and respiratory therapy education, making these professionals more vulnerable to ethical challenges. Additionally, physicians often have a deeper understanding of patient conditions and prognosis than nurses and respiratory therapists do, enabling them to process more clinical data on disease progression. Regarding the determination of whether a patient has reached the stage of futile medical treatment and the recommendation to transition toward end-of-life care, physicians are better prepared psychologically than nurses and respiratory therapists, which influences the extent of the ethical challenges they experience. Regarding affiliated departments, the results of this study reveal that professionals in surgical and pediatric intensive care units reported greater struggles regarding the right to life. This greater struggle regarding the right to life may occur because patients in surgical and pediatric intensive care units are not typically terminally ill but rather critically ill due to trauma, accidents, or neonatal conditions. Health care professionals in these units tend to adopt a more aggressive resuscitative approach, leading to heightened internal conflicts. Conflicts regarding unclear definitions of terminal illness were greatest among professionals in pediatric intensive care units, followed by those in general ward units. These findings suggest that policymakers and professional associations should establish clinical standards to determine when patients have entered the terminal stage, ensuring adherence to optimal ethical practices.^4,6

CONCLUSION

The top three ethical challenges faced by health care professionals in WLST are unclear definitions of terminal illness, divergent attitudes among family members, and uncertainty in responsibility for extubation. During the WLST process, the top five stressors are the withdrawal of life-support systems or extubation, disclosure of the patient’s condition, grief counseling and emotional support for family members, execution of the withdrawal process through multidisciplinary collaboration, and policies or procedures. Health care professionals who are unmarried, have no childbirth experience, are younger, have lower seniority, or work in pediatric or surgical intensive care units are at higher risk of experiencing ethical challenges in WLST.

Clinical applications and recommendations

This study proposes the following recommendations: First, for critically ill noncancer patients and neonates, the definition of terminal illness and the appropriate timing and context for WLST should be thoroughly discussed by specialized medical associations to develop standards and guidelines, reducing ethical challenges in clinical practice. Second, WLST should be guided by clear objectives and a structured care plan. A multidisciplinary collaboration model should be adopted, using family meetings to facilitate communication with family members and considering the patient’s medical condition, family preferences, religious beliefs, values, and cultural background to reach a consensus and informed decision. Third, for groups at high-risk of facing ethical challenges, such as pediatric and surgical intensive care unit staff, ethical scenarios involving WLST should be incorporated into training programs and educational curricula. A multifaceted educational approach that includes case studies and scenario-based simulations can encourage critical thinking and reflection, reducing conflicts and challenges. Fourth, enhancing health care professionals’ skills in disclosing medical conditions and promoting a multidisciplinary decision-making model is essential to ensure consensus and cooperation among medical teams. Fifth, establishing emotional support mechanisms, such as psychological counseling, emotional relief programs, and peer support systems, can help reduce stress among health care professionals. Finally, to reduce ethical challenges related to end-of-life disputes, efforts to promote advance care planning among the public should be strengthened.

For nursing practice, this study underscores the urgent need to equip nurses with communication skills to effectively manage family expectations and deliver sensitive information regarding end-of-life decisions. Nurses often serve as frontline providers in WLST and are pivotal in implementing emotional and spiritual care for both patients and families. Thus, scenario-based training in ethical decision-making and grief support should be integrated into continuing education for nurses. Moreover, clear role delineation and institutional protocols are necessary to reduce ambiguity in extubation responsibilities, which was identified as a significant source of stress among nurses. Establishing structured debriefings and emotional support systems can further help nurses process ethical stress and avoid burnout. This research highlights the critical role nurses play in WLST and calls for policy and educational reforms that better support nursing professionals in ethically complex care environments.

LIMITATIONS

This study has some limitations. First, because of constraints in human resources and funding, sample collection was limited to teaching hospitals in central Taiwan. Future research should expand the sample to hospitals of different levels and across counties and cities. Second, due to the limited willingness of medical personnel to participate, only nine cases were studied, limiting the generalizability of the findings.